ArticlePDF Available

Retrospective analysis of four-year injury data from the Infantry Training Centre, Catterick

  • Defence Primary Healthcare United Kingdom

Abstract and Figures

Introduction Musculoskeletal injury (MSKI) represents a considerable threat to the effectiveness and productivity of military organisations globally. The impact on the medical chain, occupational disposal with associated loss of working days and associated financial burden have far-reaching consequence. The moral and legal responsibility to reduce avoidable injuries through risk assessment and prevention strategies is fundamental to governance and a key component of best practice. Methods A retrospective observational analysis was performed of 4101 MSKIs presenting from a total inflow of 10 498 British Army Infantry recruits recorded over four consecutive training years between 2012 and 2016. Injury incidence, site, type and week of training were recorded and analysed. Results The total incidence of all MSKI was observed as 39.1%. Overuse injuries were the most common subclassification of injury type (24.5%), followed by trauma (8.8%) and then stress fractures (5.7%). Causes of medical discharge over a four-year cumulative incidence were from overuse injuries (59.3%), stress fractures (21.5%) and trauma (19.2%). 45.5% of all MSKIs presented within the first eight weeks of training. Conclusions MSKI data highlighted the requirement for a comprehensive service evaluation of the Combat Infantryman’s Course and subsequent justification for the introduction of an injury prevention intervention — Project OMEGA.
Content may be subject to copyright.
Heagerty R, etal. J R Army Med Corps 2018;164:35–40. doi:10.1136/jramc-2017-000777
Original paper
Retrospective analysis of four-year injury data from
the Infantry Training Centre,Catterick
Robert Heagerty,1 J Sharma,1,2 J Cayton,1,3 N Goodwin3
To cite: HeagertyR,
SharmaJ, CaytonJ, etal.
J R Army Med Corps
1PCRF ITS, Physio Department,
Catterick Garrison, UK
2Teesside University,
Middlesborough, UK
3RRU Catterick, UK
Correspondence to
Major Robert Heagerty, PCRF,
Infantry Training Centre, Vimy
Barracks, Catterick, Catterick
Garrison, North Yorkshire DL9
3PS, UK; robheagerty@ me. com
Received 7 March 2017
Revised 23 June 2017
Accepted 27 June 2017
Published Online First
Introduction Musculoskeletal injury (MSKI) represents
a considerable threat to the effectiveness and produc-
tivity of military organisations globally. The impact on the
medical chain, occupational disposal with associated loss
of working days and associated financial burden have
far-reaching consequence. The moral and legal responsi-
bility to reduce avoidable injuries through risk assessment
and prevention strategies is fundamental to governance
and a key component of best practice.
Methods A retrospective observational analysis was
performed of 4101 MSKIs presenting from a total inflow
of 10 498 British Army Infantry recruits recorded over four
consecutive training years between 2012 and 2016. Injury
incidence, site, type and week of training were recorded
and analysed.
Results The total incidence of all MSKI was observed
as 39.1%. Overuse injuries were the most common
subclassification of injury type (24.5%), followed by
trauma (8.8%) and then stress fractures (5.7%). Causes
of medical discharge over a four-year cumulative inci-
dence were from overuse injuries (59.3%), stress frac-
tures (21.5%) and trauma (19.2%). 45.5% of all MSKIs
presented within the first eight weeks of training.
Conclusions MSKI data highlighted the requirement
for a comprehensive service evaluation of the Combat
Infantryman’s Course and subsequent justification for
the introduction of an injury prevention intervention —
Project OMEGA.
Infantry training courses within the UK military
The Infantry Training Centre (ITC), Catterick is a
phase 1 and 2 military training establishment with
capacity to provide instruction to up to 4000 recruits
per year.1 The Combat Infantryman’s Course (CIC)
is considered the most physically arduous and
demanding of all initial military training courses
in the British Army1–3 and is delivered over a
minimum of 26 weeks to recruits allocated to eight
training companies under command of two Infantry
Training Battalions. 1 Infantry training Battalion
consists of five standard (line) infantry divisional
companies, and 2 Infantry Training Battalion
consists of guards, parachute regiment and Gurkha
soldiers. The training content is a blend of generic
military training and unit-specific soldiering skills.
In addition, the Guards Company has a focus on
drill, and the Parachute Company focuses on the
arduous parachute selection course.1 Gurkha
training, lasting 39 weeks, is the longest due to
its incorporation of additional packages such as
linguistics, cultural education, tactical close combat
and martial arts training. The intent for all training
teams is to transform young civilians into class 3
infanteers ready to join the British Army.
Musculoskeletal injuries in military
Ongoing service evaluation and quality improve-
ment is an imperative reflected in the ITC’s mission
statement.4 Musculoskeletal injury (MSKI) is
recognised both in the UK and globally as a signif-
icant challenge to military efficiency.1 5–16 MSKI
has a negative impact on morbidity, training time,
resources and manning.1 7–20 It is also a potential
threat to the effectiveness and productivity of the
ITC, with a subsequent impact on the supply of
trained personnel to the wider military.1 4 14 18 20 The
increased burden on the medical chain, loss of days
in training due to temporary downgrade, place-
ment on light duties and potential risk of subse-
quent medical discharge (MD) present an ongoing
challenge to organisational effectiveness.1 14 18 The
associated wastage contributes to compromised
operational capability and presents a significant
financial loss.1 5 7 11 14 16 18–21 As potentially career
and therefore life-changing events, in the physical
domain but seen increasingly from a psychological
perspective, MSKI can have significant impact on
the individuals affected.1 2 5 7 10 11 18 20–25
Key messages
Incidence of musculoskeletal training injuries
within military populations is recognised
globally to have detrimental impact on wastage
and organisational effectiveness.
There is a strong professional and moral
responsibility to understand and address the
causation of potentially reducible training
Injuries to the lower limb, specifically the
knee, were the most frequently reported, while
highimpact activity was identified as the most
common cause.
Injury incidence was the highest in the first
two weeks of infantry training, with the majority
of all injuries reported in the first eight weeks.
Of all subclassifications of injury, overuse
injuries were the most common cause of
medical discharge.
Effective injury prevention strategies should
address the multifactorial nature of military
training injuries. Professional and moral
accountability resulted in the implementation of
Project OMEGA.
on 3 August 2018 by guest. Protected by copyright. R Army Med Corps: first published as 10.1136/jramc-2017-000777 on 22 August 2017. Downloaded from
36 Heagerty R, etal. J R Army Med Corps 2018;164:35–40. doi:10.1136/jramc-2017-000777
Original paper
Although the global appetite to identify effective injury
prevention strategies is strong, population-specific epide-
miological data are limited.11 Accumulating accurate and
meaningful injury data is a prerequisite to identifying injury
patterns and determining the direction of subsequent
interventions.5 7 10–12 18–20 22–27 The aim of this paper is to present
retrospective trend analysis of the incidence and subclassifications
of all MSKI episodes referred to a physiotherapy department over
a four-year period.
The ITC Primary Care Rehabilitation Facility (PCRF) has main-
tained a register of injury data since 1 April 2012. Administrative
staff prospectively enter MSKI data with senior physiotherapy
staff. Causality categories are divided into injuries attributed
directly to infantry recruit training (phase 1 and 2), injuries
due to playing sport and injuries sustained in non-working time
(Table 1). Every MSKI is presented as a new separate case. Repeat
injuries within four weeks of initial presentation are recorded
within the original recorded episode of care. Overuse injury
(non-fracture) were distinguished from overuse stress fracture.
A single training year runs between 1 April and 31 March.
The spreadsheet is password-protected and managed in accor-
dance with Caldicott guidelines. The MSKI data between 1 April
2012 to 31 March 2016 were reviewed for targeted trend anal-
ysis. Non-training MSKI such as those acquired from domestic
causes, for example road traffic accidents or weekend sports, were
excluded. In addition, injuries reported by personnel on military
short courses were not included in this analysis. This paper did not
investigate intercompany injury patterns.
Data analysis
Data were analysed descriptively by site, type, rate and time of
presentation. All data were independently checked for accuracy
by the clinical administration assistant, as well as three senior
members of the physiotherapy management team, prior to anal-
ysis. All MSKI data were considered in relation to the total annual
recruit inflow to ITC. All recruits entering ITC are nominally
and numerically registered according to their allocated training
company. The baseline data of total number of recruit inflow
for each regiment were retrieved from the Training, Administra-
tion and Financial Management Information System, and were
cross-referenced and confirmed as accurate against recruit intake
figures recorded by the ITC G7 Training Cell and key statis-
tical database for the School of Infantry. The injury data were
extracted and presented for all individual recruits commencing
the respective training years.
During this four-year period of study, 4101 MSKIs were
referred to the PCRF from a total inflow of 10 498 recruit
trainees. Table 2 presents the classification of MSKI by type as
a percentage of both the annual recruit inflow as well as the
number of referrals to physiotherapy for each training year. The
incidence of all reported MSKIs sustained by recruits across all
training companies undertaking the CIC varied from 32.5% to
50.1%, representing a total of four-year cumulative incidence,
with a 95% CI of 39.1% (95% CI 38.1 to 40.0).
Type of injury
The most common subclassification of injury type was overuse,
24.5% (95% CI 23.7 to 25.4), followed by trauma, 8.8% (95%
CI 8.3 to 9.4), and stress fractures 5.7% (95% CI 5.3 to 6.2).
Overuse injuries were observed to be the most common injury
(62.8%, 95% CI 61.3 to 64.2) presented by recruits to the
physiotherapy department, with all overuse MSKIs (including
stress fracture) representing a four-year cumulative incidence
of 77.5% (Table 2). Overuse combined with stress fractures
represents a combined four-year cumulative incidence of 30.2%
of total recruit inflow, which equates to more than one in every
three recruits sustaining an overuse injury. The four-year cumu-
lative incidence for traumatic injuries was 8.8% (95% CI 8.3
to 9.4) of the total recruit inflow. The incidence of previously
sustained pre-existing injuries incurred prior to the individual
commencing recruit training at ITC equated to 11.9% (95% CI
11.3 to 12.5) of (total four-year cumulative incidence) annual
inflow or 30.4% (four-year cumulative incidence) of all injuries
referred to the PCRF.
Site of injury
Figure 1 shows the most common sites of diagnosed MSKI with
a 95% CI. The majority of injuries occurred to the lower limb,
most commonly at the knee (21.0%–25.8%), followed by the
ankle (16.6%–19.3%).
Reported causation
Figure 2 describes the injury causation with 95% CI. Notably,
for the four consecutive training years fast loaded marching
(‘tabbing’) has consistently been the most reported cause of
MSKI (36.9% to 40.1%), followed by trauma (19.8% to 23.0%),
field exercise (13.7% to 19.1%) and running (16.7% to 20.4%).
Week of injury
Figure 3 and table 3 illustrate the distribution of all MSKIs
presented during this four-year period. The week of peak injury
Table 1 Data fields included within the injury database
Patient Injury Training Rehabilitation summary
Service number Date of injury Week of Trg Days in physiotherapy
Unit (ie, Infantry Training Centre) Date presented to Primary Care
Rehabilitation Facility
Days out of training Weeks in physiotherapy
Regt(ie, line infantry, para, guards or Gurkha) Injury type(ie, trauma, overuse) Days in rehabilitation platoon Number physiotherapy appointments
Ethnicity Injury site(ie, spine/hip/knee/ankle/foot) Date of discharge Weeks in rehabilitation platoon
Gender Pre-existinginjury status Outcome(ie, return to training/medical
Stress fracture site
Stress fracture diagnosis
Patient perceived cause injury
on 3 August 2018 by guest. Protected by copyright. R Army Med Corps: first published as 10.1136/jramc-2017-000777 on 22 August 2017. Downloaded from
Heagerty R, etal. J R Army Med Corps 2018;164:35–40. doi:10.1136/jramc-2017-000777
Original paper
incidence was found to vary annually. However, the highest
recorded incidence of injury (across all four years) were observed
in weeks 1 (7.0%), 2 (8.5%), 3 (6.9%), 4 (6.8%), 8 (6.4%) and
14 (6.4%), with the majority (45.5%: 95% CI 44.0 to 47.1) of
all MSKIs presented in the first eight weeks of infantry training.
MSKI resulting in MD
Table 4 presents the MD according to subclassification of
MSKI. The most common causes of MD were overuse injuries
(non-stress fracture), 59.3% (95% CI 55.9 to 62.7), followed
by stress fracture, 21.5% (95% CI 18.8 to 24.5), and trauma,
19.2% (95% CI 16.7 to 22.1).
This review analysed 4101 MSKIs referred to the physiotherapy
department from a total inflow of 10 498 recruit trainees at the
ITC between 1 April 2012 and 31 March 2016. The incidence
of all reported injuries sustained by recruits across all training
companies undertaking the CIC ranged from 32.5% to 50.1%
of the total recruit inflow. This equates to a four-year annual
cumulative incidence of 39.1%, which falls within the values
(20%–59%) reported previously across other military popula-
tions.1 5 9 16 24
There is some variation in the pattern of annual injury incidence
over the last four training years. It is recognised that MSKIs are
multifactorial in origin, and as such it may be tenuous to attri-
bute a single intervention to either increments or reductions
in incidence. However, it may be suggested that targeted injury
prevention strategies could have contributed to the reduced injury
incidence in training years 2013/2014 and 2015/2016. These strat-
egies included the reduction in unnecessary ‘junk’ mileage previ-
ously incurred by the recruits transiting across the camp between
training serials, as well as the introduction of nutritional training
supplements. Similarly, the introduction of a variety of new mili-
tary boots in April 2013 may have contributed to a reduction in
ankle and foot injuries, as well as contributed to the lower attrition
rates during this period. Equally, it is interesting that prior to the
introduction of new military footwear, injuries to the foot were
the third most common (Figure 1), but then replaced by calf/shin
injuries after 2013.
Overuse (non-stress fracture) lower limb injuries have
consistently been the most common subclassification of MSKI
referred to physiotherapy in the recruit population at ITC
with a four-year cumulative incidence of 62.8% of all refer-
rals. Stress fractures are considered multifactorial in causation;
however, ultimately they represent a pathological response to
the body’s inability to efficiently dissipate applied load. The
nature of these injuries is such that the recruit is removed
from training for an extended period (up to four months) of
rehabilitation. As a consequence of overloading, they there-
fore represent a significant subset of the overuse injury cohort.
Consequently, total overuse MSKI (including stress fractures)
represent a four-year cumulative incidence of 77.5% of all
referrals to physiotherapy.
The prevalence of knee injuries (21.0%–25.8%; see figure 1)
observed in this study reflects findings previously described across
the literature, that between 20% and 40% of military training
injuries involve the knee.5 7 As a multiaxial joint it is capable
of multiplanar movement and as such is inherently susceptible
to both traumatic and overuse MSKI. In addition, both prox-
imal and distal movement dysfunctions can contribute to kinetic
changes, which may result in the development of MSKI at the
knee.27 Consequently, kinetic chain movement stability (static
Table 2 Musculoskeletal injury type as a percentage of total recruit inflow and referral to physiotherapy
Type 2012/2013 2013/2014 2014/2015 2015/2016
Four-year cumulative
incidence 95% CI
Total Inflow: 10 498
Total referrals to
Incidence rate: 39.1% 38.13% to 40.0%
Overuse 921
Inflow: 24.5% 23.7% to 25.4%
Physiotherapy: 62.8% 61.3% to 64.2%
Trauma 307
Inflow: 8.8 .% 8.3% to 9.37%
Physiotherapy: 22.6% 21.3% to 23.9%
Stress fracture 175
Inflow: 5.7% 5.3% to 6.2%
Physiotherapy: 14.7% 13.6% to 15.8%
Pre-enlistment 411
Inflow: 11.9% 11.3% to 12.5%
Physiotherapy: 30.4% 28.9% to 31.8%
on 3 August 2018 by guest. Protected by copyright. R Army Med Corps: first published as 10.1136/jramc-2017-000777 on 22 August 2017. Downloaded from
38 Heagerty R, etal. J R Army Med Corps 2018;164:35–40. doi:10.1136/jramc-2017-000777
Original paper
Figure 1 The most common area of injury (as a % of total injuries referred to physiotherapy).CIC,Combat Infantryman’s Course.
Figure 2 The most common reported cause of injury (as a % of injuries referred to physiotherapy).CIC,Combat Infantryman’s Course.
on 3 August 2018 by guest. Protected by copyright. R Army Med Corps: first published as 10.1136/jramc-2017-000777 on 22 August 2017. Downloaded from
Heagerty R, etal. J R Army Med Corps 2018;164:35–40. doi:10.1136/jramc-2017-000777
Original paper
and dynamic) should be carefully considered when constructing
injury prevention strategies.
There is a strong moral responsibility to investigate mech-
anisms of injury mitigation while professional accountability
to meet both internal and external drivers of governance to
prevent harm, reduce injury incidence and enhance service
delivery are constantly sought.5 14 Strategies specifically
designed to address the cause and mechanisms of injury have
shown the most benefit.10 Traditionally, a reduction in the abso-
lute volume of exercising mileage has been the most effective
intervention. A study of US Marine recruits showed that a 40%
(22 mile) reduction in running distance was associated with
a 54% reduction in stress fracture incidence during a Corps
Boot Camp with no significant change in run times.5 Similar
outcomes were obtained with Australian Army recruits, where
running was replaced with a graduated programme of loaded
foot marches resulting in a reduction of all lower limb injuries
by 43% and more specifically a reduction in knee injuries by
53%.4 Another study found that recruits undertaking initial
military training who ran an average of 11 miles per week
reported 27% more lower limb injuries than those running an
average of five miles per week.26
Lower limb stress fracture rates are reported to range globally
from 0.8% to 6.9% across initial entry military training popu-
lations.6 8 10 It is encouraging that the ITC has demonstrated a
reduction in annual incidence from a peak of 8.9% in 2013/2014
down to 4.7% in 2015/2016 (Table 1); however, mechanisms
to reduce all subclassifications of overuse MSKI must be inves-
tigated. The incidence of traumatic injuries has progressively
reduced from a four-year peak of 12.6% in 2013/2014 to a low
of 7.1% in 2015/2016. This may be a reflection of improving
health and safety management through increasingly robust
risk assessment as well as education of both training teams and
recruits. Excluding pre-enlistment injuries, traumatic MSKI, the
second most common subclassification of injury type, repre-
sented a four-year cumulative incidence of 8.8% (95% CI 8.3
to 9.4) of the total recruit inflow. Pre-enlistment MSKIs are
excluded from pure comparison with other subclassifications
as they represent a combination of both overuse and traumatic
injuries. Sustained high impact activities have consistently been
the most common cause of all MSKI at ITC. This is in keeping
with a plethora of international studies that acknowledge these
activities as potentially modifiable extrinsic factors for overuse
MSKI in both military and civilian populations.1 5 7 8 11 14 18–22
Forty-six per cent of all MSKIs were attributed to activity
within the first eight weeks of training, with noticeable peaks
between weeks 3 and 4 and again between weeks 8 and 10
(Table 3 and Figure 3). Despite the lack of knowledge regarding
recruits’ pre-enlistment fitness or the quality, quantity and
nature of their previous physical activity levels, it is reasonable
to suggest that, from a purely physiological perspective, those
individuals reporting overuse MSKI found difficulty coping with
the content, type, intensity and volume of the training. This is
particularly likely considering the incidence of overuse injury
in the first 12 weeks. Ultimately, this indicates a mismatch in
physical capacity/capability versus applied tissue loading, and
suggests a requirement to address this balance throughout the
course but particularly during the first half of training. Stress
Figure 3 Incidence of musculoskeletal injury attributed to specific week of training (as a % of injuries referred to physiotherapy).CIC,Combat
Infantryman’s Course.
Table 3 Cumulative percentage of total musculoskeletal injuries reported by week of training
Week of
training 2012/2013 2013/2014 2014/2015 2015/2016
Four-year cumulative
incidence 95% CI
4 25.4%(n=357) 22.6%(n=218) 27.4%(n=251) 21.3%(n=174) 24.4% (n=1000) 23.1% to 25.7%
8 47.5%(n=666) 42.8%(n=413) 47.2%(n=433) 43.5%(n=355) 45.5%(n=1867) 44.0% to 47.1%
16 77.8%(n=1091) 77.6%(n=748) 77.9%(n=715) 74.8%(n=611) 77.2%(n=3165) 75.9% to 78.4%
on 3 August 2018 by guest. Protected by copyright. R Army Med Corps: first published as 10.1136/jramc-2017-000777 on 22 August 2017. Downloaded from
40 Heagerty R, etal. J R Army Med Corps 2018;164:35–40. doi:10.1136/jramc-2017-000777
Original paper
fractures and all other (non-stress fracture) overuse injuries are
the subclassification of MSKI that are most likely to result in
subsequent MD (Table 4). This further reiterates the impact
that overuse MSKI has had on infantry recruits, resources of the
medical services, delivery of training, wastage of injured recruits
and ultimately organisational effectiveness. Successful strategies
designed to address the prevention of these MSKIs would there-
fore have far-reaching effect.
Careful consideration and modification of risk factors can
reduce the incidence of all injuries. Specific consideration of
the environment (terrain and climate) along with progressive
increments in distance, intensity and frequency accompanied by
adequate periods for rest and recovery have been advised.1 19–22
This is particularly relevant to those recruits who sustain overuse
injuries and serves as a recommended area for consideration in
future reviews of the content of infantry training at ITC. The
finding that 30% of injuries presenting to the PCRF were pre-en-
listment suggests the need for further analysis to investigate the
relationship between previous injury, performance and training
outcomes. The results of a follow-up investigation may have
implications for pre-enlistment medical screening criteria.
The prevalence of training injuries observed at ITC is not
unique to the British Army. The observations made from this
four-year analysis are consistent with those reported across
other NATO military populations.5–7 11 21–23 The responsibility
to investigate and address the cause is firmly recognised. Indeed,
a sense of urgency is reported, with strong recommendations
that proportional attention should be therefore dedicated to
the prevention of these potentially reducible injuries.5 7 10 11 18–20
These data have served as a basis for the introduction of an inte-
grated service evaluation and provided justification for the intro-
duction of an injury prevention strategy — Project OMEGA.15
If successful, this initiative could have a favourable impact on
injury incidence rates, time and finance lost to injury, as well
as identify areas for potential improvement to the content and
delivery of physical development training within the ITC.
It is imperative that accurate surveillance data are used to guide
the application of evidence-based interventions in order to
reduce the incidence of potentially avoidable MSKI. This four-
year retrospective analysis of recruit infantry training at ITC has
provided essential baseline data that could be used as rationale
for future injury prevention strategies.
Acknowledgements The authors acknowledge the considerable support of Col
Dalal L/RAMC, Col Byers L/RAMC, Lt Col Tingey Co Sp Bn ITC, Lt Col Booker RAMC,
Mrs S Mclaren, as well as the staff of the Medical Centre and PCRF at ITC Catterick.
Contributors All authors contributed to the collation, writing and editing of this
Competing interests None declared.
Provenance and peer review Not commissioned; internally peer reviewed.
© Article author(s) (or their employer(s) unless otherwise stated in the text of the
article) 2018. All rights reserved. No commercial use is permitted unless otherwise
expressly granted.
1 Sharma J, Greeves JP, Byers M, et al. Musculoskeletal injuries in British Army recruits:
a Prospective study of diagnosis-specific incidence and rehabilitation times. BMC
Musculoskelet Disord 2015;16:106.
2 Wilkinson DM, Rayson MP, Bilzon JL. A physical demands analysis of the 24-
week british Army Parachute Regiment recruit training syllabus. Ergonomics
3 Sharma J, Golby J, Greeves J, et al. Biomechanical and lifestyle risk factors for
medial tibia stress syndrome in army recruits: a prospective study. Gait Posture
4 Williams AP. Commandant’s Directive: Commandant School of Infantry, Infantry
Training Centre. Catterick, 2015.
5 Bullock SH, Jones BH, Gilchrist J, et al. Prevention of physical training-related injuries
recommendations for the military and other active populations based on expedited
systematic reviews. Am J Prev Med 2010;38:S156–81.
6 Jacobs JM, Cameron KL, Bojescul JA. Lower extremity stress fractures in the military.
Clin Sports Med 2014;33:591–613.
7 Jones BH, Bullock SH. A Model Process for Setting Military Injury Prevention Priorities
and Making Evidence-Based Recommendations for Interventions. 2005. Military
Training Task Force White Paper.
8 Leggat PA, Smith DR. Military training and musculoskeletal disorders. J Musculoskelet
Pain 2007;15:25–32.
9 Kaufman KR, Brodine S, Shaffer R. Military training-related injuries: surveillance,
research, and prevention. Am J Prev Med 2000;18:54–63.
10 Popovich RM, Gardner JW, Potter R, et al. Effect of rest from running on overuse
injuries in army basic training. Am J Prev Med 2000;18(3 Suppl):147–55.
11 Taanila H, Suni Philajamaki J, Matiyila VM, et al. BMC Musculoskeletal Disorders
12 Cooper DR. TSACA- A review of the Literature. physical preparation methods for
Combat operations-a Narrative review of the literature: dept of Defence. J Aust
Strength & Conditioning 2014;22:44–9.
13 Nunkoosing. Factors affecting the likelihood of lower limb overuse injuries in PARA
recruits during CIC-Preliminary Study.An analysis by The Parachute Regiment Training
Company, Infantry Training Centre, Catterick Report, 2014.
14 Sharma J. The development and evaluation of a management plan for musculoskeletal
injuries in british Army recruits: a series of exploratory trials on medial tibia stress
syndrome. Teesside University, 2013. http:// tees. openrepository. com/ tees/ handle/
10149/ 312900.
15 Heagerty RDH, Prior S, Newton P. Project OMEGA - Developing the Combat Athlete, 2016.
16 Sharma J, Dixon J, Dalal S, et al. Musculoskeletal injuries in British Army recruits: a
prospective study of incidence in different Infantry Regiments. J R Army Med Corps
17 Turner A, Humes A. Strength & conditioning for british soldiers, 2013.
18 Blacker SD, Wilkinson DM, Bilzon JL, et al. Risk factors for training injuries among
British Army recruits. Mil Med 2008;173:278–86.
19 Brushoj C, Larsen K, Albrecht-Beste E, et al. Prevention of Overuse Injuries by a
concurrent exercise program in Subjects exposed to an increase in training load:
a randomised controlled trial of 1020 Army Recruits. Am J of Sports Medicine
20 Sharma J, Weston M, Batterham AM, et al. Gait retraining and incidence of medial
tibial stress syndrome in army recruits. Med Sci Sports Exerc 2014;46:1684–92.
21 Lauersen JB, Bertelsen DM, Andersen LB. The effectiveness of exercise interventions
to prevent sports injuries: a systematic review and meta-analysis of randomised
controlled trials. Br J Sports Med 2014;48:1–8.
22 Kahanov L, Eberman LE, Games KE, et al. Diagnosis, treatment, and rehabilitation
of stress fractures in the lower extremity in runners. Open Access J Sports Med
23 Heir T, Glomsaker P. Epidemiology of musculoskeletal injuries among norwegian
conscripts undergoing basic military training. Scand J Med Sci Sports 1996;6:186–91.
24 Peterson L, Renstrom P. Sports Injuries their Prevention and treatment. 3rd Edn. UK:
Martin Dunitz, 2001.
25 Warden SJ, Davis IS, Fredericson M, et al. Management and prevention of bone stress
injuries in long-distance runners. J Orthop Sports Phys Ther 2014;44:749–65.
26 Jones BH, Cowan DN, Knapik JJ. Exercise, training and injuries. Sports Med
27 Chuter VH, Janse de Jonge XA. Proximal and distal contributions to lower extremity
injury: a review of the literature. Gait Posture 2012;36:7–15.
Table 4 Musculoskeletal injury resulting in medical discharge as a percentage of injury type
Type 2012/2013 2013/2014 2014/2015 2015/2016
Four-year cumulative
incidence(%) 95% CI
Stress fracture 18.0% (n=48) 25.9%(n=45) 23.1%(n=42) 20.8%(n=37) 21.5 18.8% to 24.5%
Overuse(non-fracture) 60.7%(n=162) 55.2%(n=96) 55.7%(n=105) 62.9%(n=112) 59.3 55.9% to 62.7%
Trauma 21.4%(n=57) 19.0%(n=33) 19.2%(n=35) 16.3%(n=29) 19.2 16.7% to 22.1%
on 3 August 2018 by guest. Protected by copyright. R Army Med Corps: first published as 10.1136/jramc-2017-000777 on 22 August 2017. Downloaded from
... [10][11][12] These global and national discrepancies in injury incidence are likely, at least in part, a result of an inconsistent application of injury definitions 8,9 and data collection methods. 4,8,10,11 Nevertheless, musculoskeletal injuries to the lower extremity and lower back are consistently reported as the most common during BMT, 5,7,13,14 with the majority of injuries diagnosed as overuse (cumulative microtrauma). 7,8,15,16 However, only recruits who actively seek medical attention (e.g., physiotherapy, nursing, doctor, or medical assistant records) 7,8,15,17 or experience time-loss (e.g., days of restricted training and hospital days) 1 are typically captured in injury statistics. ...
... 35,38 The greatest number of self-reported incident injuries were observed in week 1, likely a response to the new, potentially unfamiliar, stressors of BMT. 3,13 It is also important to recognize that any reported problem would likely have been the first (incident occurrence) to that specific body location. Appropriately, this may explain the steep decline in incident injuries following week 1, given the 30-day gap rule was used to avoid overestimating incident injuries. ...
... Although the costs associated with implementing additional injury surveillance should be recognized, it is also important to acknowledge the costs associated with enlisting and training recruits, irrespective of whether they complete training or not. 2,43 Considering injury during BMT can result in lengthy periods of rehabilitation, delayed training completion, and discharge, 13,44 there is arguably a compelling economic argument for improved injury surveillance to help minimize training disruption and reduce the costs associated with injury and attrition. 2,43 Although typically used as an injury surveillance tool, the OSTRC questionnaires have also been suggested as a potential daily monitoring tool, 20 and in sport the risk of sustaining a "time-loss" injury appears amplified if preceded by a self-reported injury-related problem. ...
Full-text available
Introduction The injury definitions and surveillance methods commonly used in Army basic military training (BMT) research may underestimate the extent of injury. This study therefore aims to obtain a comprehensive understanding of injuries sustained during BMT by employing recording methods to capture all physical complaints. Materials and methods Six hundred and forty-six recruits were assessed over the 12-week Australian Army BMT course. Throughout BMT injury, data were recorded via (1) physiotherapy reports following recruit consultation, (2) a member of the research team (third party) present at physical training sessions, and (3) recruit daily self-reports. Results Two hundred and thirty-five recruits had ≥1 incident injury recorded by physiotherapists, 365 recruits had ≥1 incident injury recorded by the third party, and 542 recruits reported ≥1 injury-related problems via the self-reported health questionnaire. Six hundred twenty-one, six hundred eighty-seven, and two thousand nine hundred sixty-four incident injuries were recorded from a total of 997 physiotherapy reports, 1,937 third-party reports, and 13,181 self-reported injury-related problems, respectively. The lower extremity was the most commonly injured general body region as indicated by all three recording methods. Overuse accounted for 79% and 76% of documented incident injuries from physiotherapists and the third party, respectively. Conclusions This study highlights that injury recording methods impact injury reporting during BMT. The present findings suggest that traditional injury surveillance methods, which rely on medical encounters, underestimate the injury profile during BMT. Considering accurate injury surveillance is fundamental in the sequence of injury prevention, implementing additional injury recording methods during BMT may thus improve injury surveillance and better inform training modifications and injury prevention programs.
... 8 We use the term 'lower limb overuse injuries' throughout this paper to capture both types of injury. Furthermore, multiple studies have found that injury rates are highest in the early weeks of training, [8][9][10] when recruits are not yet conditioned. ...
... A comprehensive multiyear study of all ITC courses found a significantly higher injury rate (86% vs 48%, p<0.001) and lower first time pass rate (38% vs 56%, p=0.02) on CIC(PARA) compared with CIC. 10 The majority of these injuries were lower limb overuse injuries, 9 and the study conclusion was that injury prevention strategies for The Parachute Regiment and overuse injury should receive high priority. 10 Previous interventions in CIC(PARA) have included the on June 2, 2020 by guest. ...
... Injury data were extracted from a data set compiled by the ITC Medical Centre. 9 The data covered only recruits on CIC(PARA), and specifically lower limb overuse injuries (both stress fractures and MTSS). Data were recorded as time of first clinical manifestation of symptoms (based on self-reporting) rather than time of recording at the Medical Centre. ...
Introduction Military initial training results in a high incidence of lower limb overuse injuries (stress fractures and medial tibial stress syndrome). This study aimed to determine whether the distance travelled by recruits, both on and off duty, was a risk factor for overuse injury. Methods 14 male airborne infantry recruits from three training platoons carried global positioning system receivers throughout the first 19 weeks of basic military training. Total distance travelled each day was recorded. This was compared with time of clinical manifestation of 52 lower limb overuse injuries (stress fractures and medial tibial stress syndrome) collected from the 276 airborne infantry recruits in the period immediately preceding the study. Results Recruits travelled significantly farther than the UK average male population in 17 of 18 measured weeks. Pearson correlation between distance travelled per week and injuries was not significant (p=0.4448); however, correlation between distance travelled per week and injuries two weeks later was significant (p=0.0263). A generalised linear model found distance travelled as a significant covariate (p=0.0144) to the expected number of injuries two weeks later. Conclusion Recruits travel long distances during basic training, particularly in the first few weeks when they are not yet conditioned. This distance travelled is likely a contributing risk factor to the high incidence of overuse injuries seen during training, and strategies to reduce this distance should be explored.
... 5,10 One active population that often carries heavy equipment while running, increasing the risk for AT disorders and overuse injuries, is military personnel. 13 Physical activity, including distance running with and without added mass, is a part of every soldier's training regimen. Soldiers often need to run with additional gear in the field. ...
... Data over four consecutive years analyzed injury incidence in British Army Infantry recruits showed that nearly one out of every four recruits sustained an overuse injury, most in the ankle and calf, with fast loaded marching and running. 13 When examining the US Marine Corps recruits in basic training, Achilles tendinitis was the third most common podiatric injury, behind foot stress fractures and ankle sprains. 17 Women are becoming more active in the military, are 2-10 times more likely to suffer a musculoskeletal injury, and 67% more likely to receive a physical disability discharge from the Army compared to male soldiers. ...
... Our research is the first to report the severity and burden of injuries to police recruits. Lower limb injuries made up most of the overall injury burden and is comparable to military basic training [27,28]. However, shoulder injuries were the second highest injury area/region as far as injury burden in our police recruit cohort, suggesting prevention strategies for shoulder injuries also be prioritised. ...
... Muscle/tendon and ligament/joint capsule injuries made up most of the overall injury burden. Conversely, in military basic training, bone stress injuries are a substantial cause of injury burden [27,28], however in our study this only represents a very small proportion of the injuries (1.3%), which is very likely due to differences in basic training program requirements and structure between the professions. The common injury tissue/pathology types presented within our study are more comparable to those of football players [29]. ...
Full-text available
Purpose A lack of published epidemiological data among police recruits presents a major challenge when designing appropriate prevention programs to reduce injury burden. We aimed to report the injury epidemiology of Western Australian (WA) Police Force recruits and examine sex and age as injury risk factors. Methods Retrospective analyses were conducted of prospectively collected injury data from WA Police Force recruits between 2018–2021. Injury was defined as ‘time-loss’ and injury incidence rate per 1000 training days (Poisson exact 95% confidence intervals) was calculated. For each region and type of injury, the incidence, severity, and burden were calculated. The association between age, sex, and injury occurrence were assessed using Cox regression time-to-event analysis. Results A total of 1316 WA Police Force recruits were included, of whom 264 recruits sustained 304 injuries. Injury prevalence was 20.1% and the incidence rate was 2.00 (95%CI 1.78–2.24) injuries per 1000 training days. Lower limb injuries accounted for most of the injury burden. Ligament/ joint injuries had the highest injury tissue/pathology burden. The most common activity injuring recruits was physical training (31.8% of all injuries). Older age (Hazard Ratio = 1.5, 95%CI = 1.2 to 1.9, p = 0.002) and female sex (Hazard Ratio = 1.4, 95%CI = 1.3 to 1.6, p < 0.001) increased risk of injury. Conclusion Prevention programs targeting muscle/tendon and ligament/joint injuries to the lower limb and shoulder should be prioritised to reduce the WA Police Force injury burden. Injury prevention programs should also prioritise recruits who are over 30 years of age or of female sex, given they are a higher risk population.
... The high rate of both acute and overuse MSKI sustained to the lower extremity during rucksack marching is consistent with American and British infantry training. 23,24 It is well established that MSKI sustained during rucksack marching have been associated with increases in duration, frequency, load and terrain. 13,23,24 As these factors are training related, the effects of MSKI sustained during rucksack marching may be reduced by implementing evidence-based training programs similar to this study. ...
... 23,24 It is well established that MSKI sustained during rucksack marching have been associated with increases in duration, frequency, load and terrain. 13,23,24 As these factors are training related, the effects of MSKI sustained during rucksack marching may be reduced by implementing evidence-based training programs similar to this study. ...
Full-text available
Objectives Determine the feasibility of implementing an evidence-based training program compared to a control during a basic infantry training course, and compare their effectiveness on measures of injuries and associated burdens. Design Prospective, cohort, feasibility study. Method Infantry candidates awaiting course between 01-April-2019 and 31-March-2020 were invited to participate while those releasing from the military, awaiting occupational transfer or having >5 medical employment limitation days were excluded. Consenting participants were allocated to an infantry course prospectively scheduled to host either the evidence-based program or a control. The evidence-based program adapted modified physical training strategies from previous studies reporting reduced injuries in recruits and was supervised by certified fitness professionals, while the control was at the discretion of infantry instructors. Results With the exception of intervention duration which was limited due to operational factors, all feasibility outcomes were met including a recruitment rate of 171/203 = 84.2% and an intervention adherence of 126/144 = 87.5%. Stakeholders reported that the evidence-based program implementation was feasible, posing a manageable demand on resources without compromising operations. Evidence-based program participants reported 68% fewer overuse musculoskeletal injuries, 296 fewer medical employment limitation days and 11 fewer attritions than control participants. Conclusion An evidence-based training program is feasible to implement on a basic infantry training course, and results in fewer musculoskeletal injuries, medical employment limitation days and attrition. Given these results, this program should be generalizable for a full experimental trial, and may be scaled for intermediate/advanced infantry and/or other combat occupation courses to promote an evolution towards evidence-based training.
... 5 According to medical data from the British Army, the incidence of MSIs varies from 32.5% to 50.1% across several training companies. 6 The most common types of MSIs in armed forces are joint sprains, muscle strains, and other injury types that are also common in athletic populations, such as iliotibial band syndrome and stress fractures. 7,8 Among military personnel, MSIs are the leading cause of high costs of medical care 9−11 and are related to limitedduty days, 9 which threaten military readiness. ...
Full-text available
Context: This study evaluates the effect of nonexercise interventions on the reduction of risk for musculoskeletal injuries in armed forces. Evidence acquisition: A database search was conducted in PubMed/MEDLINE, Embase, Cochrane Library, CINAHL, SPORTdiscus, Greylit, Open Grey, the WHO trial registry, and the reference lists of included articles up to July 2019. RCTs and cluster RCTs evaluating nonexercise interventions for the prevention of musculoskeletal injuries in armed forces compared with any other intervention(s) or no intervention were eligible for inclusion. Data extraction and risk of bias assessment were done by 2 authors independently, followed by meta-analysis and Grading of Recommendations Assessment, Development, and Evaluation assessment, if appropriate. Evidence synthesis: This study included 27 articles with a total number of 25,593 participants, examining nutritional supplementation, prophylactic medication, and equipment modifications with mostly high or unclear risk of bias. Meta-analysis and Grading of Recommendations Assessment, Development, and Evaluation assessment could be performed for 3 comparisons: custom-made insoles versus no insoles, tropical/hot-weather boots versus leather boots, and shock-absorbing insoles versus nonshock-absorbing insoles interventions, all showing the very low quality of evidence. Some evidence was found to support the preventive effect of shock-absorbing insoles, basketball shoes, padded polyester socks, calcium with vitamin D supplementation, only calcium supplementation, protein supplementation, and dynamic patellofemoral braces. Conclusions: Although an evidence base for the efficacy of preventive interventions for musculoskeletal injuries in armed forces is weak, there are some indications for the preventive effect of shock-absorbing insoles, basketball shoes, padded polyester socks, supplementation of calcium alone or combined with vitamin D, protein supplementation, and dynamic patellofemoral braces on the incidence of musculoskeletal injuries.
Background: Injuries are a common occurrence in military recruit training, however due to differences in the capture of training exposure, injury incidence rates are rarely reported. Our aim was to determine the musculoskeletal injury epidemiology of military recruits, including a standardised injury incidence rate. Methods: Epidemiological systematic review following the PRISMA 2020 guidelines. Five online databases were searched from database inception to 5 th May 2021. Prospective and retrospective studies that reported data on musculoskeletal injuries sustained by military recruits after the year 2000 were included. We reported on the frequency, prevalence and injury incidence rate. Incidence rate per 1000 training days (Exact 95% CI) was calculated using meta-analysis to allow comparisons between studies. Observed heterogeneity (e.g., training duration) precluded pooling of results across countries. The Joanna Briggs Institute Quality Assessment Checklist for Prevalence Studies assessed study quality. Results: This review identified 41 studies comprising 451,782 recruits. Most studies (n=26; 63%) reported the number of injured recruits, and the majority of studies (n=27; 66%) reported the number of injuries to recruits. The prevalence of recruits with medical attention injuries or time-loss injuries was 22.8% and 31.4%, respectively. Meta-analysis revealed the injury incidence rate for recruits with a medical attention injury may be as high as 19.52 injuries per 1000 training days; and time-loss injury may be as high as 3.97 injuries per 1000 training days. Longer recruit training programs were associated with a reduced injury incidence rate (p=0.003). The overall certainty of the evidence was low per a modified GRADE approach. Conclusion: This systematic review with meta-analysis highlights a high musculoskeletal injury prevalence and injury incidence rate within military recruits undergoing basic training with minimal improvement observed over the past 20 years. Longer training program, which may decrease the degree of overload experienced by recruit, may reduce injury incidence rates. Unfortunately, reporting standards and reporting consistency remain a barrier to generalisability. Systematic Review Registration: PROSPERO (Registration number: CRD42021251080)
Introduction As the focus of the Royal Air Force (RAF) shifts from sustained to contingency operations and the number of personnel is reduced, the burden of retained, medically downgraded personnel may affect operational readiness. The main aims were: to define the prevalence of morbidity leading to permanent medical downgrading; to determine at risk populations and identify areas for improvement. Method Database of personnel referred to the RAF Medical Board was analysed from January 2012 to October 2013 and January 2017 to December 2019. Patients were excluded if they did not require a formal medical board; incomplete and duplicate entries were also excluded. The primary reason for medical downgrade was categorised with an ICD-10 code. Further subanalysis compared musculoskeletal disease with age, individual trade groups and anatomic region. Results 2% of RAF service personnel were permanently downgraded annually. Musculoskeletal disease was the leading cause for permanent downgrade across both periods: 58% and 49%. Female personnel were at a greater risk of musculoskeletal downgrade compared with males. Spinal and knee pathology were the leading cause for downgrading among ‘high risk’ personnel. Personnel downgraded due to musculoskeletal pathology were often retained in a limited role with 10% and 5% retained as medically fully deployable. 14% and 12% of personnel downgraded due to musculoskeletal pathology were medically discharged. Conclusion Musculoskeletal disease was the leading cause for permanent medical downgrades in the RAF. A greater proportion of downgraded personnel with musculoskeletal conditions were retained in service with medical limitations rather than medically discharged.
Introduction The Israel Defense Forces (IDF) has strict protocols for the diagnosis and treatment of stress fractures wherein diagnosis is clinical with imaging used for persistent symptoms only. The purpose of this study was to examine the incidence of clinical and radiological stress fractures during IDF combat training. Methods Medical records of all soldiers enlisted to combat training between 2014 and 2017 were scanned for the diagnosis of stress fractures. We examined the imaging tests ordered (plain radiographs and bone scans) and their results and the time between the clinical diagnosis to imaging tests. Results During 4 years, 62 371 soldiers (10.1% women) had started combat training, and 3672 of them (5.9%) were diagnosed with clinical stress fractures. Radiographs were ordered for 53.5% of those diagnosed, of whom 29.7% also had a bone scan. Some 42% of radiographs were taken within 21 days. Radiographs were positive for stress fractures in 11.1% of tests. Bone scans showed evidence of stress fractures in 49.7%, of which 49.2% diagnosed stress fractures in multiple bones. Conclusion The high percentage of negative radiographs may indicate towards alternative causes for symptoms. Performing the radiograph before or after 21 days did not affect workup results diverting from current belief that later radiographs will be more sensitive. Multiple stress fractures are a common finding, indicating that the increased training load puts the whole musculoskeletal system at increased risk for injury. Research results may necessitate a revision of clinical guidelines for the diagnosis of stress fractures in military trainees.
This chapter focuses on presentations that are generally nontraumatic in nature and often have a higher prevalence in a military environment due to the nature of a service person’s role. Carrying extra weight in a Bergen while marching at a set pace over a long distance can lead to the development of pain or injury in the lower limb. Exercise-induced leg pain (EILP) is an umbrella term used to encompass conditions such as tendinopathy, chronic exertional compartment syndrome (CECS), popliteal artery entrapment syndrome (PAES), and medial tibial stress syndrome (MTSS). Other conditions, such as superficial peroneal nerve entrapment syndrome (SPNES), can also occur due to overuse and subsequent compression, but it more typically follows an episode of trauma. While these conditions are separate clinical entities in their own right, there is often an overlap in how they present, which places strong emphasis on a thorough history taking and a detailed objective assessment. In the military environment, these conditions are generally managed with multidisciplinary input from general practice, orthopedics, sport and exercise medicine, rehabilitation, radiology, pain management, and psychology in order to return the service person to active duty as quickly as possible.
Full-text available
Background Musculoskeletal injuries and attrition incurred during basic military training are a significant socioeconomic burden across many Defence Forces. In order to plan an injury prevention strategy, the purpose of this study was to quantify the regiment-specific musculoskeletal injury patterns and training outcomes. Methods This was a prospective observational study of the Parachute (n=734), Guards (n=1044), Line (n=3472) and Gurkha (n=458) Regiments of the British Army recruits during a 26-week basic military training programme over a 2-year period. The participant demographic characteristics were: age 18.9 years (SD±2.3), height 176.5 cm (SD±7.80), mass 69 kg (SD±9.7) and body mass index 22.14 kg/m² (SD±2.5). Results The incidence of injuries (86%, 46%, 48% and 10%) was significantly different (p<0.001) as were the first time pass out rates (p=0.02) of 38%, 51%, 56% and 98% for Parachute, Guards, Line and Gurkha, respectively. Overuse injuries were more frequently reported than both acute and recurrent injuries in all regiments (X²=688.01, p<0.01). Conclusions The disparity in injury incidence and training outcome between Infantry Regiments suggests that the demands of training be taken into account when devising injury prevention strategies.
Full-text available
Musculoskeletal injuries during initial military training are a significant medical problem facing military organisations globally. In order to develop an injury management programme, this study aims to quantify the incidence and rehabilitation times for injury specific diagnoses. This was a prospective follow-up study of musculoskeletal injuries in 6608 British Army recruits during a 26-week initial military training programme over a 2-year period. Incidence and rehabilitation times for injury specific diagnoses were recorded and analysed. During the study period the overall incidence of musculoskeletal injuries was 48.6%, and the most common diagnosis was iliotibial band syndrome (6.2%). A significant proportion of the injuries occurred during the first 11 weeks of the programme. The longest rehabilitation times were for stress fractures of the femur, calcaneus and tibia (116 ± 17 days, 92 ± 12 days, and 85 ± 11 days, respectively). The combination of high incidence and lengthy rehabilitation indicates that medial tibial stress syndrome had the greatest impact on training, accounting for almost 20% of all days spent in rehabilitation. When setting prevention priorities consideration should be given to both the incidence of specific injury diagnoses and their associated time to recovery.
Full-text available
Stress fractures account for between 1% and 20% of athletic injuries, with 80% of stress fractures in the lower extremity. Stress fractures of the lower extremity are common injuries among individuals who participate in endurance, high load-bearing activities such as running, military and aerobic exercise and therefore require practitioner expertise in diagnosis and management. Accurate diagnosis for stress fractures is dependent on the anatomical area. Anatomical regions such as the pelvis, sacrum, and metatarsals offer challenges due to difficulty differentiating pathologies with common symptoms. Special tests and treatment regimes, however, are similar among most stress fractures with resolution between 4 weeks to a year. The most difficult aspect of stress fracture treatment entails mitigating internal and external risk factors. Practitioners should address ongoing risk factors to minimize recurrence.
Full-text available
Synopsis: Bone stress injury (BSI) represents the inability of bone to withstand repetitive loading, which results in structural fatigue and localized bone pain and tenderness. A BSI occurs along a pathology continuum that begins with a stress reaction, which can progress to a stress fracture and, ultimately, a complete bone fracture. Bone stress injuries are a source of concern in long-distance runners, not only because of their frequency and the morbidity they cause but also because of their tendency to recur. While most BSIs readily heal following a period of modified loading and a progressive return to running activities, the high recurrence rate of BSIs signals a need to address their underlying causative factors. A BSI results from disruption of the homeostasis between microdamage formation and its removal. Microdamage accumulation and subsequent risk for development of a BSI are related both to the load applied to a bone and to the ability of the bone to resist load. The former is more amenable to intervention and may be modified by interventions aimed at training-program design, reducing impact-related forces (eg, instructing an athlete to run "softer" or with a higher stride rate), and increasing the strength and/or endurance of local musculature (eg, strengthening the calf for tibial BSIs and the foot intrinsics for BSIs of the metatarsals). Similarly, malalignments and abnormal movement patterns should be explored and addressed. The current commentary discusses management and prevention of BSIs in runners. In doing so, information is provided on the pathophysiology, epidemiology, risk factors, clinical diagnosis, and classification of BSIs. Level of evidence: Therapy, level 5.
Full-text available
Gait retraining, comprising bio-feedback and/or an exercise intervention, might reduce the risk of musculoskeletal conditions. The purpose was to examine the effect of a gait retraining program on medial tibial stress syndrome incidence during a 26 week basic military training regimen. A total of 450 British Army recruits volunteered. On the basis of a baseline plantar pressure variable (mean foot balance during the first 10% of stance), participants classified as at-risk of developing medial tibial stress syndrome (n = 166) were randomly allocated to an intervention (n = 83) or control (n = 83) group. The intervention involved supervised gait retraining, including exercises to increase neuromuscular control and flexibility (3 sessions per week) and bio-feedback enabling internalization of the foot balance variable (1 session per week). Both groups continued with the usual military training regimen. Diagnoses of medial tibial stress syndrome over the 26 week regimen were made by physicians blinded to group assignment. Data were modelled in a survival analysis using Cox regression, adjusting for baseline foot balance and time to peak heel rotation. The intervention was associated with a substantially reduced instantaneous relative risk of medial tibial stress syndrome versus control, with an adjusted hazard ratio of 0.25 (95% confidence interval, 0.05 to 0.53). The number needed to treat to observe one additional injury-free recruit in intervention versus control at 20 weeks was 14 (11 to 23) participants. Baseline foot balance was a nonspecific predictor of injury, with a hazard ratio per 2-SD increment of 5.2 (1.6 to 53.6). The intervention was effective in reducing incidence of medial tibial stress syndrome in an at-risk military sample.
Background: It has been hypothesized that a period of rest from running in the early weeks of basic military training will prevent stress fractures among recruits.Design: Modification of running schedules in companies of Army recruits undergoing basic military training was assigned.Setting/ Participants: Six male training companies were enrolled and followed during their 8 weeks of basic military training at Fort Bliss, Texas, in summer/fall 1989.Intervention: Intervention companies were asked to rest from running during the second, third, or fourth week of basic military training.Main outcome measures: Data were collected from questionnaires, anthropometric measurements, Army physical fitness tests, company training logs, and medical record abstraction of all clinic visits.Results: Among the 1357 enrolled male recruits, there were 236 (17%) with overuse injury and 144 (11%) with traumatic injury, resulting in 535 clinic visits and 1927 training days lost. Stress fracture/reaction rates varied from 3 to 8 per 100 recruits among the intervention companies and 2 to 7 per 100 recruits among the non-intervention companies. Total injury rates were 18 to 35 per 100 recruits in the intervention companies and 18 to 29 per 100 recruits in the non-intervention companies.Conclusions: The study provided no evidence for a protective effect on overuse injuries of resting from running for 1 week early in basic military training. There was varied physical training among the companies, however, with variation of injury rates that likely related to factors other than the intervention.
Stress fractures of the lower extremities are common among the military population and athletes. Service members are typically at the greatest risk for stress fracture during basic combat training and initial entry-level training, and it may be related to poor indices of entry-level physical fitness. The purpose of this study is to review the epidemiology and incidence of stress fractures and common stress fractures' diagnosis and treatment and to investigate modifiable and nonmodifiable risk factors and injury prevention. In the soldier or athlete who presents with activity-related pain, stress fractures should be given significant consideration during the clinical evaluation.
Many of us winter sport enthusiasts will still remember the last Winter Olympic Games in Vancouver 2010: fantastic organisation and weather—a real ‘folk festival’ with street parties up in Whistler and in downtown Vancouver. However, we also remember a high number of injuries and tears of disappointment among athletes in the spectacular snowboard and ski freestyle races at Cypress Mountain specifically. In these cross-disciplines on snow, inspired by motocross, athletes compete in heats of four and race head-to-head at high speed through jumps and obstacles of varying difficulty. The International Olympic Committee (IOC) injury surveillance during the 2010 Olympic Winter Games reported snowboard and freestyle cross as high-risk disciplines, and women were specifically prone.1 In many cases, these injuries prevented the athlete from further participation in the Olympics. Snowboard and freestyle are under close scrutiny What are the IOC and the International Winter Federations doing to make the sports safer? Injury reports from the last skiing and snowboarding World Cup seasons indicate that knee and head injuries are the most common injuries.2 Catastrophic head injuries, such as skull fractures or cerebral haemorrhages, are rare but despite that there were …